Modifier 57 - discussing with a general surgeon

jccoder

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Would modifier 57 be used on the facility side, physician side or both when the ED physician admits a patient to the OR for appendectomy after discussing with a general surgeon? Or would mod 57 only be used by the general surgeon?
 

pkulczycki

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Modifier 57 can only be used by the general surgeon "IF" & "ONLY IF" the surgeon performed a consult (met the requirements of a consult and then made the decision to perform the surgery. A coder must be careful using modifier 57. All of the requirements of a consult must be met and the actual decision of performing a surgical procedure must be decided after preforming the exam and reviewing diagnostic tests.

I hope this helps.

Peggy
 

dmaec

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jccoder - I'd give the decision for surgery to the whoever made that decision (form what you wrote, I'd say ED doc made the call - surgeon was ready for the procedure). I don't see anywhere in my CPT guidelines that the decision for surgery code .57 can only be used on a "consult" code, or that it can only be used by surgeons. I read the definition as: "an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service." However, I do believe it can only be used in connection with major surgical procedures (90 day global). I'm sure the appendectomy has a 90 day global.
Personally, I've never used it on an ED E/M - I have used it in the past on several regular office visit E/M's that resulted in the decision to do a major surgical procedure.
 

Treetoad

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I've never seen this documented anywhere, but I would expect the only provider who would have a need for this modifier would be the one who is performing the actual surgical procedure. This modifier would be used either the day of surgery or one day prior indicating the "decision for surgery" was made at this visit. It would prevent the service from being denied "global" to the surgery. Another provider's service wouldn't deny as global. I also don't believe its use is limited to consultations as I've used it on hospital admissions, new/est office visits and ED visits.
 

dmaec

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hi Treetoad - yes, I've used it on new/est EM's also, the day before and day of surgery. but, (and maybe I used the code wrong) ...I have used it on the provider (PCP) who decided to send the person to surgery but wasn't the surgeon. Example being, pt patient presented with severe abdominal pain - vomiting, to PCP (on a walk-in emergency type visit) - PCP examined, ran tests - determined appendicitis and need for surgery ASAP - PCP did not do the appendectomy but was the one that made that decision for it - I appended the .57 modifier to the PCP's E/M so it wouldn't get caught up in a global issue.
I'd appreciate your advice on this - do you think I shouldn't have used the .57?
thanks!
 

Treetoad

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Hi Donna,
I don't think using modifier 57 is necessary for anyone other than the surgeon. If the PCP service denied, it would be an error on the carrier's part and I would appeal.
 

dmaec

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hmm... I see :) Now I'll have to find out just how they paid! - Hopefully putting the modifier on it didn't mess things up either. I'll check in on that more with billing. Thanks for the input!
 
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